Update of surgical treatment of polydactyly.

PURPOSE OF REVIEW: Polydactyly presents with variable extent of duplication and may involve preaxial/radial (hand)/medial (foot), postaxial/ulnar (hand)/lateral (foot) or central duplication. This review will summarize recent advancements in the surgical management of this common entity. RECENT FINDINGS: Modifications to classification systems aim to help guide surgical management of polydactyly. Attempts have been made at quantifying preoperative angulation of the duplicated digits to minimize the chance of residual or recurrent deformity after surgical reconstruction. As a result, consideration should be given to the need for soft tissue correction vs. osteotomy to optimize the clinical outcome. On-top plasty is an option that may be beneficial in 'unequal' preaxial polydactyly, where neither duplicate is preferred on its own. SUMMARY: Polydactyly is one of the most common congenital anomalies in the hands and feet. Determination of surgical intervention often begins with classification systems that exist, which primarily separate these into preaxial, postaxial, and central. Referral for surgical consideration is indicated, given the management is often surgical.

ErbB2 blockade with Herceptin (trastuzumab) enhances peripheral nerve regeneration after repair of acute or chronic peripheral nerve injury.

OBJECTIVE: Attenuation of the growth supportive environment within the distal nerve stump after delayed peripheral nerve repair profoundly limits nerve regeneration. Levels of the potent Schwann cell mitogen neuregulin and its receptor ErbB2 decline during this period, but the regenerative impact of this change is not completely understood. Herein, the ErbB2 receptor pathway is inhibited with the selective monoclonal antibody Herceptin (trastuzumab) to determine its significance in regulating acute and chronic regeneration in a rat hindlimb. METHODS: The common peroneal nerve of Sprague-Dawley rats was transected and repaired immediately or after 4 months of chronic denervation, followed by administration of Herceptin or saline solution. Regenerated motor and sensory neurons were counted using a retrograde tracer 1, 2, or 4, weeks after repair. Distal myelinated axon outgrowth after 4 weeks was quantified using histomorphometry. Immunofluorescent imaging was used to evaluate Schwann cell proliferation and epidermal growth factor receptor (EGFR) activation in the regenerating nerves. RESULTS: Herceptin administration increased the rate of motor and sensory neuron regeneration and the number of proliferating Schwann cells in the distal stump after the first week. Herceptin also increased the number of myelinated axons that regenerated 4 weeks after immediate and delayed repair. Reduced EGFR activation was observed using immunofluorescent imaging. INTERPRETATION: Inhibition of the ErbB2 receptor with Herceptin unexpectedly enhances nerve regeneration after acute and delayed nerve repair. This finding raises the possibility of using targeted molecular therapies to improve outcomes of peripheral nerve injuries. The mechanism may involve a novel inhibitory association between ErbB2 and EGFR. Ann Neurol 2016;80:112-126.

Pragmatic detection of anxiety and depression in a prospective cohort of voice outpatient clinic attenders.

OBJECTIVE: To evaluate diagnostic performance of the emotional domain of the VoiSS questionnaire compared with the Hospital Anxiety and Depression Scale (HADS). DESIGN: Cross-sectional questionnaire study. SETTING: Tertiary referral centre voice clinic. PARTICIPANTS: 210 consecutive voice clinic patients. MAIN OUTCOME MEASURES: Screening with VoiSS and HADS questionnaires. Paired comparison, correlation, multinomial logistic regression and receiver-operating characteristic (ROC) curve analysis. RESULTS: A total of 177 returned complete data sets. Ninety-six patients (54.2%) had functional dysphonia, and 81 (45.8%) had organic laryngeal disorders. Mean total VoiSS score = 39.7/120 (standard deviation (sd) 22.2). Mean emotional VoiSS subscale = 7.6/22 (sd 7.5). Mean HADS anxiety = 6.5/21 (sd 5.2) and depression mean = 7.1/21 (sd 4.8). There were 35 (20%) borderline anxiety and/or depression scores and 30 (17%) scores considered positive for 'caseness'. There was strong correlation between emotional VoiSS and HADS anxiety (Spearman's Rho = 0.68, P < 0.001) and HADS depression (Spearman's Rho = 0.62, P < 0.001). ROC curve analysis exhibited significant association between emotional VoiSS and HADS 'caseness' (area under curve = 0.88). In addition, functional dysphonia patients had lower mean VoiSS and HADS scores than patients with identifiable laryngeal abnormalities. CONCLUSION: The VoiSS emotional subscale strongly correlates with HADS anxiety and depression scores and could be used as a measure of psychological distress. This could allow targeted psychological strategies, without additional psychometric questionnaires. Functional dysphonia has less association with psychological distress than certain organic laryngological disorders.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure.

BACKGROUND: The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention. OBJECTIVES OF REVIEW: To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: 'Glasgow Benefit Inventory' and 'GBI' were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015. EVALUATION METHOD: Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded. RESULTS: A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or 'reassurance'. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit CONCLUSIONS: The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as 'reassurance'. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: a systematic review of randomised controlled trials.

BACKGROUND: Incidence rates of Meniere's syndrome/disease vary considerably from 157 per 100 000 in the United Kingdom to 15 per 100 000 in the United States. A wide range of treatments are used for the treatment of the condition with no consensus on the most effective intervention. OBJECTIVES: To assess the effectiveness of the Meniett device in reducing the frequency and severity of vertigo in Meniere's syndrome/disease. SEARCH METHODS: The Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific abstracts; ICTRP and additional sources for published and unpublished trials were searched. The date of the last search was 13th May 2014. SELECTION CRITERIA: Four randomised controlled trials (RCTs) were identified that compared the efficacy of the Meniett device versus a placebo device in patients with Meniere's 'disease' as defined by the AAOO criterion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility and risk of bias and extracted data. The outcome data were dichotomous for all the included trials. MAIN RESULTS: The four RCTs compared 123 patients with the Meniett device against 114 patients with the placebo device from four RCT's over a follow-up period of 2 weeks to 4 months. There was a significant overall 61% reduction in the frequency of vertigo in both groups (mean no vertigo days per month of 8-3). However, this reduction was not significantly different between the two groups in any study or on meta-analysis [mean difference in vertigo-free days between Meniett and placebo device of 0.77 days over a 1-month period (95% CI - 0.82, 1.83) P = 0.45]. There were also no substantive data to support a greater reduction in the severity of the vertigo or any other outcome with the Meniett device compared with the placebo device. AUTHORS CONCLUSIONS: No evidence was found to justify the use of the Meniett device in Meniere's syndrome/disease.

Alternative Nerve Coaptations: End-To-Side and Beyond.

Modern end-to-side (ETS) nerve transfers have undergone several permutations since the early 1990's. Preclinical data have revealed important mechanisms and patterns of donor axon outgrowth into the recipient nerves and target reinnervation. The versatility of ETS nerve transfers can also potentially address several processes that limit functional recovery after nerve injury by babysitting motor end-plates and/or supporting the regenerative environment within the denervated nerve. Further clinical and basic science work is required to clarify the ideal clinical indications, contraindications, and mechanisms of action for these techniques in order to maximize their potential as reconstructive options.

Evaluation of motor and sensory neuron populations in a mouse median nerve injury model.

BACKGROUND: Peripheral nerves can regenerate and restore function after injury but this process is hindered by many factors including chronic denervation, motor end-plate resorption and Schwann cell senescence. Forelimb injury models in rodents are becoming increasingly popular as they more accurately reflect the physiology and biomechanics of upper extremity nerve injuries. However several aspects of this surgical model remain poorly characterized. NEW METHOD: C57Bl/6 mice underwent enumeration of median nerve motor and sensory neuron pools using retrograde labeling with or without nerve transection. Distal histomorphometry of uninjured mouse median nerves was also examined. Baseline reference values of volitional forelimb grip strength measurements were determined and the rate of neural elongation was also estimated. RESULTS: We identified 1363 ± 165 sensory and 216 ± 16 motor neurons within the uninjured dorsal root ganglia (DRG) and ventral spinal cord, respectively. Eight days following injury, approximately 34% of motoneurons had elongated a distance of 5 mm beyond the repair site 8 days following injury. Volitional grip strength decreased 50% with unilateral median nerve transection and was negligible with contralateral flexor tendon tenotomy. COMPARISON WITH EXISTING METHOD: Our spinal cord and DRG harvesting technique presented here was technically straightforward and reliable. Estimates of motor and sensory neuron numbers for the mouse median nerve compared favourably with studies using intramuscular injection of retrograde neurotracer. Histomorphometry data was consistent with and reinforced reference values in the literature. CONCLUSIONS: This study provides data that further develops an increasingly popular surgical model for studying peripheral nerve injury and repair.

The Effectiveness of a Self-Directed e-Learning Module on Trainee Knowledge and Confidence during Plastic Surgery Clinical Rotations.

Background: Exposure to plastic surgery is limited during medical school. This makes rotations for clinical clerks and off-service residents challenging. Available resources are often too detailed and overwhelming. Having an accessible, concise, and interactive plastic surgery e-learning module reviewing core plastic surgery topics could help prepare incoming trainees for their rotations. Methods: An e-learning module was created using text, images, and in-house recorded video recordings. Two cohorts were recruited: control cohort (n = 9), who completed their plastic surgery rotation without use of the module, and an interventional cohort (n = 18), who completed the rotation with use of the module. A demographic survey, a 20-question multiple-choice knowledge test, and self-reported confidence score were completed by both cohorts at the end of their plastic surgery rotations. The intervention cohort also completed the knowledge test at the beginning of their rotation to establish baseline. Knowledge and confidence scores were compared using two-tailed, unpaired, nonparametric analyses (Mann-Whitney test). Results: Learners from the intervention cohort reported a 95% module completion rate and found the resource "extremely helpful" (average Likert of 4.8/5). Learners indicated that they were very likely to recommend the resource to others (average Likert 4.9/5). The intervention cohort scored significantly higher on the knowledge test compared with the control cohort (P = 0.008), and on average reported higher confidence levels; however, this was not statistically significant (P = 0.057). Conclusion: An accessible and concise module on core plastic surgery concepts enhances learner knowledge and confidence during plastic surgery clinical rotations.

Abductor mechanism tears in primary total hip arthroplasty.

INTRODUCTION: Tears of the abductor mechanism of the hip are well recognized, but poorly understood. Little is known of the effect of demographics and pathology on prevalence of abductor mechanism tears or the impact on clinical outcome. METHODS: This prospective study analysed the effect of age, gender, medical co-morbidity and social deprivation on prevalence of abductor mechanism tears of the hip in 835 consecutive patients undergoing total hip arthroplasty (THA) between 2003 and 2011. Effect on clinical outcome relating to presence of abductor mechanism tear was analysed in a subset at pre-op and at 1 year post-operation using the Oxford hip score (OHS). RESULTS: The prevalence of abductor mechanism tears was 25.4 % (n = 212). Female patients (p < 0.001), older patients (p = 0.001) and those of lower socioeconomic status (p < 0.001) were significantly more likely to have a pre-operative abductor mechanism tear. In older socially deprived females the predicted rate of tear is 70.9 %. The aetiology of the hip disease (p = 0.593) or presence of any specific co-morbidity (p = 0.085-0.929) had no significant effect on the prevalence of abductor mechanism tears. In patients with protrusion or dysplasia there was an increased prevalence of tears (p = 0.002). There was no significant difference in pre-operative (p = 0.775) or post-operative (p = 0.604) OHSs regardless of the tears when the tears were recognized and treated at the time of THA. CONCLUSIONS: Tears are increasingly prevalent in women of advancing years and lower socioeconomic status which should be considered when planning operative approach in this demographic. When recognised and repaired there is no difference in the clinical outcome for those with abductor mechanism tears of the hip.

Optimizing the Timing of Peripheral Nerve Transfers for Functional Re-Animation in Cervical Spinal Cord Injury: A Conceptual Framework.

Loss of upper extremity function following spinal cord injury (SCI) can have devastating consequences on quality of life. Peripheral nerve transfer surgery aims to restore motor control of upper extremities following cervical SCI and is poised to revolutionize surgical management in this population. The surgery involves dividing an expendable donor nerve above the level of the spinal lesion and coapting it to a recipient nerve arising from the lesional or infralesional segment of the injured cord. In order to maximize outcomes in this complex patient population, refinements in surgical technique need to be integrated with principles of spinal cord medicine and basic science. Deciding on the ideal timing of nerve transfer surgery is one aspect of care that is critical to maximizing recovery and has received very little attention to date in the literature. This complex topic is reviewed, with a focus on expectations for spontaneous recovery within upper motor neuron components of the injury, balanced against the need for expeditious re-innervation for lower motor neuron elements of the injury. The discussion also considers the case of a patient with C6 motor complete SCI in whom myotomes without electrodiagnostic evidence of denervation spontaneously improved by 6 months post-injury, thereby adjusting the surgical plan. The relevant concepts are integrated into a clinical algorithm with recommendations that consider maximal opportunity for spontaneous clinical improvement post-injury while avoiding excessive delays that may adversely affect patient outcomes.

Delayed-Type Hypersensitivity Reaction to Red Tattoo Ink Triggered by Ledipasvir/Sofosbuvir for Hepatitis C: A Case Report.

Tattoos have become increasingly popular worldwide making adverse effects from tattoos a growing concern. In our report, we present a 51-year-old man who developed an unusual allergic reaction to the red ink portions of his tattoos that coincided with the initiation of ledipasvir/sofosbuvir treatment for his hepatitis C. Clinical and histological features were consistent with a delayed-type hypersensitivity reaction to red ink.

Determining the parameter space for effective oxygen depletion for FLASH radiation therapy.

There has been a recent revival of interest in the FLASH effect, after experiments have shown normal tissue sparing capabilities of ultra-high-dose-rate radiation with no compromise on tumour growth restraint. A model has been developed to investigate the relative importance of a number of fundamental parameters considered to be involved in the oxygen depletion paradigm of induced radioresistance. An example eight-dimensional parameter space demonstrates the conditions under which radiation may induce sufficient depletion of oxygen for a diffusion-limited hypoxic cellular response. Initial results support experimental evidence that FLASH sparing is only achieved for dose rates on the order of tens of Gy s-1or higher, for a sufficiently high dose, and only for tissue that is slightly hypoxic at the time of radiation. We show that the FLASH effect is the result of a number of biological, radiochemical and delivery parameters. Also, the threshold dose for a FLASH effect occurring would be more prominent when the parameterisation was optimised to produce the maximum effect. The model provides a framework for further FLASH-related investigation and experimental design. An understanding of the mechanistic interactions producing an optimised FLASH effect is essential for its translation into clinical practice.

Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation.

Painful neuromas (PN) and phantom limb pain (PLP) are common following amputation and are unreliably treated, which impacts quality of life. Targeted muscle reinnervation (TMR) is a microsurgical technique that repairs the severed proximal nerve end to a redundant motor nerve in the amputated stump. Evidence supports TMR as effective in treating PN and PLP; however, its adoption has been slow. This study aimed to characterize: (1) the populations experiencing post-amputation PN/PLP; (2) current trends in managing PN/PLP; and (3) attitudes toward routine use of TMR to manage PN/PLP. METHODS: A cross-sectional survey was distributed to all orthopedic surgeons, plastic surgeons, and physiatrists practicing in Ontario, via publicly available emails and specialty associations. Data were collected on demographics, experience with amputation, managing post-amputation pain, and attitudes toward routine use of TMR. RESULTS: Sixty-six of 698 eligible participants submitted complete surveys (9.5% response rate). Respondents had a greater experience with surgical management of PN (71% PN versus 10% PLP). However, surgery was considered a 3rd-line option for PN and not an option for PLP in 57% and 59% of respondents, respectively. Thirty participants (45%) were unaware of TMR as an option, and only 8 respondents have currently incorporated TMR into their practice. Many (76%) would be willing to incorporate TMR into their practice as either an immediate or delayed surgical technique. CONCLUSIONS: Despite its promise in managing post-amputation pain, awareness of TMR as a surgical option is generally poor. Several barriers to the widespread adoption of this technique are defined.

Promoting compassionate care in radiography - What might be suitable pedagogy? A discussion paper.

OBJECTIVES: Compassionate care is a core value of healthcare practice. In the post-Francis arena, the Shape of Caring review scrutinised healthcare education and training. The aim of the review was to better enable healthcare providers in delivering compassionate care and support to people with complex challenging health needs today and in the future. The review also reiterated the role of educators and universities in developing curricula capable of promoting compassionate care. Despite the review focussing upon the nursing profession, this paper suggests there is a similar role for radiography educators in delivering curricula suitable for promoting compassionate care. Potential pedagogic methods and their suitability within the radiography education setting will be considered. KEY FINDINGS: Relationships and emotions were noted as important aspects of promoting compassionate care. The themes 'practising compassionately' and 'individual and relationship factors …' are of particular relevance to education. CONCLUSIONS: Compassion remains a priority in policy which must be promoted to students as an integral aspect of healthcare education. A facilitated discussion of students' reflections around practice experiences to promote compassion is suggested. Supplemented by service user stories, students would be able to develop the skills needed to 'practise compassionately'.

Biological Benefits of Ultra-high Dose Rate FLASH Radiotherapy: Sleeping Beauty Awoken.

FLASH radiotherapy (FLASH-RT) is a technology that could modify the way radiotherapy is delivered in the future. This technique involves the ultra-fast delivery of radiotherapy at dose rates several orders of magnitude higher than those currently used in routine clinical practice. This very short time of exposure leads to the striking observation of relative protection of normal tissues that are exposed to FLASH-RT as compared with conventional dose rate radiotherapy. Here we summarise the current knowledge about the FLASH effect and provide a synthesis of the observations that have been reported on various experimental animal models (mice, zebrafish, pig, cats), various organs (lung, gut, brain, skin) and by various groups across 40 years of research. We also propose possible mechanisms for the FLASH effect, as well as possible paths for clinical application.

Neurofilament-histomorphometry comparison in the evaluation of unmyelinated axon regeneration following peripheral nerve injury: An alternative to electron microscopy.

BACKGROUND: Currently, assessment of unmyelinated axon regeneration is limited to electron microscopy (EM), which is expensive, time consuming and not universally available. This study presents a protocol to estimate the number of unmyelinated axons in a regenerating peripheral nerve without the need for electron microscopy. NEW METHOD: The common peroneal nerve of Sprague-Dawley rats was transected, repaired and regenerated for 4 weeks. Two distal adjacent segments of the regenerating nerve were then processed for either conventional histomorphometry using toluidine blue or immunolabeling of neurofilament protein. Myelinated axon and total axon counts were obtained, respectively, to generate estimates of unmyelinated axon numbers, which were then compared to unmyelinated axon counts using EM from the same specimens. For comparison, unmyelinated axons were counted in an uninjured rat laryngeal nerve. RESULTS: After 4 weeks of regeneration, the estimated number of regenerating unmyelinated axons was 4044 ± 232 using this technique, representing 81.3% of the total axonal population. By comparison, the proportion of unmyelinated axons in the uninjured laryngeal nerve was 55% of the total axonal population. COMPARISON WITH EXISTING METHOD: These estimates correlate with electron microscopy measurements, both in terms of the proportion of unmyelinated axons and also by linear regression analysis. CONCLUSIONS: The neurofilament staining method correlates with electron microscopy estimates of the same nerve sections. It is useful for the efficient counting of unmyelinated axons in the regenerating peripheral nerve and can be used by laboratories that do not have access to EM facilities.

Stability in shifting sands: contemporary leadership roles in critical care.

BACKGROUND: Contemporary nursing leadership roles in critical care are a reflection of the changing environment in which critical care is provided. KEY ISSUES: In the UK, critical care nursing faces challenges in the form of: reduced number and seniority of medical staff cover for acute wards; mandated responsibility for management of patients outside of critical care units, without corresponding responsibility for managing staff; increased public and political awareness of deficits in critical care; increased use of Assistant Practitioners; and emphasis on longer-term outcomes from intensive care. EVALUATION: New leadership roles have met these challenges head on with two main foci: patient management across the acute/critical care interface and hospital wide policies and practice. CONCLUSIONS: The leadership roles examined in this paper highlight three underpinning goals: improved quality and safety of patient care; improved communication between professionals; and empowerment of junior nurses and doctors. IMPLICATIONS FOR NURSING MANAGEMENT: There has been considerable investment in strategic leadership roles for critical care nursing; evidence is developing of the return on this investment for patient and service outcomes. Consideration must now be given to the preparation, mentorship and development of leadership roles for the next generation of nurse leaders.